Ruminations by a non-academic general surgeon from the heart of the rust belt.

Tuesday, November 18, 2008

Max Baucus and Budget Neutrality

So we've all been reading lately about the Baucus plan to re-invent healthcare delivery and to save primary care in America. It's the hot topic on KevinMd right now. Most of it is over my head and, frankly, uninteresting to me. It's 100 pages of wonkish policy drivel, as far as I'm concerned. (For example, here's a paragraph from the section regarding malpractice reform: "Malpractice reform could address money and time spent on litigation, as well as improve patient and provider satisfaction with the resolution of complaints or grievances. Additionally, changes made as part of reforming the health care system would affect medical malpractice. For example, damages awarded for care necessary as a result of malpractice would be reduced because the cost of care would decrease across the board. Also, improvements in preventive care and care coordination would reduce the likelihood of risky procedures that are a source of malpractice claims." Um, whatever the hell that means. As I read the words, the only sense I can make of it is that by lowering the overall cost of health care delivery {via the genius of Max Baucus} then if there is malpractice committed, the costs of paying for care provided to correct said malpractice will be less. Circular and vapid reasoning, at best.).....Just give me a bunch of of patients with peritonitis and I'm happy.

One thing to address, however. The plan clearly spells out an intention for "budget neutral" increases in the remuneration of primary care physicians. That means taking money out of the pockets of specialists and sticking it in the white lab coats of your local family docs. Obviously, primary care isn't paid commensurate to the work they do. Reimbursement is tilted overwhelmingly toward proceduralists. Dermatologists and gastroenterologists are making three and sometimes four times as much as the primary care provider who refers them business. As a result, medical students are fleeing careers in primary care like a bunch of gazelles that spot a lion stalking them in the savannah. Why work long hours with miserable pay when you can work less and earn more and do cool procedures instead of managing the tediousness of chronic diseases? Isn't it human nature to opt for the latter? I guess I don't blame these young kids.

With the Baucus plan, the discrepancy will be corrected by moving money from the overcompensated specialists to our poor, bedraggled primary care docs. Budget neutral. Because, you know, it's not like you could conceive of simply improving reimbursements for primary care independently of how specialists are paid. That won't do. There won't be enough money to pay for the massive federal bureaucracy soon to be created to administer the One's inchoate national health care delivery system.

In football, for the longest time, the guys who got the big contracts were the glamour positions; quarterback, running back, occasionally wide receiver. And then everyone realized that the "skill position" stars were useless you had a decent offensive line. Linemen are extremely unglamorous. You couldn't identify these behemoths if you sat next to them at the Multiplex watching Quantum of Solace. They're anonymous and large and seem to earn paychecks by banging their bodies with utmost violence against other enormous humans lined up across from them. But it became obvious that your pretty boy QB wasn't worth a mound of dirt unless you had a stud left tackle protecting his blind side. That Jim Brown-esque running back of yours was a waste of a signing bonus unless you had the beef up front to open up holes for him. So what happened is, the really good linemen started getting paid. Guys like Steve Hutchinson and Alan Faneca and Bryant McKinnie now have compensation packages not far off from what the top tier of QB's get.

So what the hell am I talking about? Another sports analogy. What else is new from me. What I'm saying is that if primary care docs and internists want to start earning what QB's, I mean specialists, make, then they better be damn good at what they do. I was chatting with one of the ID guys the other day and I noticed his list was almost three pages long. He was pissed off, too. He'd be rounding until past 6pm (this was a saturday). "Most of it's all b.s., he said. This one's a UTI. This one has a decubitus ulcer. That guy has pneumonia. This one, they thought he had a fever in the ER but he really didn't; clerical error." Dr ID pal of mine was busy with a bunch of nonsense. His group had had to hire another doc just to keep up with all the work. They literally are seeing close to 90% of the patients on the medical floors. At another hospital I cover, there are three GI groups to cover a 120 bed facility and they're all busy. This is the world internists have created themselves. A patient comes in through the ER with shortness of breath, admitting internist gives orders over the phone, consults are sent out for cardiology and pulmonology. Patient noted to have a WBC count of 12, ID consult obtained. Patient slightly anemic (hemoglobin 11.9) and a GI consult is obtained with resultant inpatient upper and lower endoscopy. Patient a little bloated after endoscopy, vomits that night; surgery consult requested. It happens constantly. Rare is the patient who comes in under the care of an internist, receives a diagnosis and treatment plan from same internist and ultimately goes home once presenting complaint issues are resolved. In happens in surgery too. I've covered for general surgeons who get medicine and ID consults on young patients who are post op from routine appendectomies. It's outrageous. The admitting physician essentially delegates the decision making and diagnostic work to specialists and then swings by every day to review the chart, work done, and to say hello to the patient. It's like Penn St football right now. Joe Paterno is 117 years old and he can hardly walk six feet without falling. He sits up in the press box during games and lets the assistant coaches pretty much call all the plays and run the game down on the sideline. Many of our younger internists are getting trained within this Joe Paterno paradigm of passive leadership.

One argument is that this simply reflects the highly litigious atmosphere of practicing medicine in America and the shotgun approach to getting consults is simply a way to CYA. Defensive medicine is certainly a source of the high cost of health care delivery in the United States and an honest attempt at malpractice reform will go a long way toward reducing a doctor's initial impulse to get MRI's on everyone with low back pain. But nothing is ever as black and white as we would like to make it. Defensive medicine is understandable. But it's important that we aren't equating lazy medicine with defensive medicine. (That line is going to receive some crack backs, I'm sure. I just hope KevinMD doesn't read this and order my subsequent slaying). If internists and primary care docs shouldered more of the work (with better pay, of course) and didn't consult everyone in the hospital for routine admissions, we would see a reduced demand for specialists and market forces alone would make it unsustainable for graduating residents to flock like lemmings to subspeciality fellowships. Primary care/internal medicine is the offensive line of health care delivery. They ought to be paid accordingly. But they're going to have to bang some bodies and get a little dirty to do so.....

17 comments:

That was the joke in Medical School that all FPs did was sit around and figure out who to consult too, back in the 80's when the "Gate Keeper" model was the new thing. Too bad you don't have to buy your ticket at the Gate anymore, just go on line, or get one from the Scalper on the corner.

Though I mostly agree with what you say, I think there is a difference between PCP's and strictly hospitalists (good ones anyways). I would say I actually had consults on less than 50% of my patients back in my hospitalist days (I am a subspecialist now). I found the overconsults usually came from PCP's with admitting priv. they would consult often based on not seeing the patient (often being in clinic). Unless it is a life/death situation or something that obviously needs a consult (say peripheral 70% blasts on a smear). I think it is embarassing to consult without doing your own H an P. I think it is embarrasing for an ID doc to get consults for pneumonia/UTI unless they are refractory to treatments (or an odd bug). Yet I saw both everyday from PCP's with admitting priv. It is one of the real big advantages of 24 hr hospitalists over PCP's with admitting priv. That is not to say every hospitalist is not a "consultist". That IMO is where a rigorous residency comes in with a VA and community hospital experience. Whatever justified complaints there may be about those systems, it is the place to get good training and be the doc.

I see this happen all the time with my fellow FPs and internists. I feel bad! when I call a cardiologist because my guy bumped his enzymes, because I know that Dr. C has a three page rounding list, two thirds of which is bogus chest pain and little old people with CHF who need diuresis. On the other hand, when Consultant writes in his note! (no phone call) recommend consult ID because patient has a fever I am peeved. It is the culture around here. Whatever happened to the Oslerian internist? I could go on, but you have said it better than I.

an FP--with pads on, ready to KSA--and wouldn't it be great to get paid what I'm worth--but will KSA regardless.

Coming out of FP residency two years ago I entered a call group of 10. I would do my weekend call, admite anywhere from 4-12 people, and consult on maybe 1 or 2 of them. Then Monday would come and I would get calls from the patients' regular docs wanting to know why I hadn't consulted everyone under the sun. Well, I wasn't trained that way. Where I went to residency, you did your own work. Consults were for when the patient needed a procedure you couldn't do or you really didn't know what was wrong and couldn't figure it out with research.

So now I am in a call group of 4 that is more willing to be doctors. Much better.

Umm speaking from ignorance here, but don't the consultants get paid for seeing consults?? I used to love getting new customers on my paper route. I could understand in the Military where you got paid the same whether you saw 1 patient or 101.

As a salaried community internist, I'm guilty of many of the things mentioned. In a group practice with a call schedule of 1 out of 8 weeks, there was only an illusion of continuity of care. I had no previous relationship with 80% of the patients presenting for admission through the ED. Certainly there was no financial incentive. So go head, turf the atypical CP to the busy private cardiology group and everyone's happy. No admission orders at 3AM for me and the cardiology group makes a couple grand with their nuclear stress test (which often could avoided with a thorough history and a less litigious society). A marginal GI bleed at midnight, admit to the GI group. Pretty cyanical, I know, but it is what it is. By choosing a salaried position, I'll burden some of the blame. I have lost the great motivator of money. I feels some shame with this admission, but it's real. I make the vast majority of my money seeing 25 patients a day in clinic.

Our group has since switched to admitting to a hospitalist service, which I truly believe has benefited the patient the most. Hospital stayd are shortened, and the quality of care has improved. But there was quite an uproar from the specialists in the hospital, as they saw their easy consult money disappear. They actually tried to get the hospitalist group kicked out, but were unsuccessful d/t the profitability of the hospitalists to the hospital (shorter stays, same medicare reimbursement). So lets not be naive about what it all comes down to. The big fat dollar. So be careful what you ask for, less you bite the hand that feeds you.

Anon 11/21: I appreciate your honest comments. As a surgeon, I don't worry too much about getting my hand bitten; a patient with an acute abdomen needs surgery no matter what. If writing about this means I lose the 100 bucks or so for the b.s. "abdominal pain" consults, then so be it. I feel lousy turning those in to the billing company anyway.

This is a complex problem - I'm guessing that the PCPs (who have only 5-10 minutes to get to the bottom of any patients' concerns) do depend on specialists more than they'd like, probably because they have to set their clinical treadmill to "sprint" just to pay their overhead. They know they can't do the kind of job they'd like to due to the time constraints, so instead of leaving the patient with incomplete answers/care, they involve more specialists.

I do worry that a sudden increase in pay (with PCPs used to the current treadmill setting) will result in an increase in salary without an increase in quality of care and time spent with the patient. Let's hope that doesn't happen. :)

Buckeye, read my post on "witchdoctor" hospitals.. i.e., which doctor should i consult.In my experience at 3 different institutions this phenomenon seems to be a function of the culture of the hospital / community. When I started my current job,it was so bad I would get calls from the nurses saying "you forgot to order the (ex.cardiology) consult" for routine low risk chest pain. No, I'd tell them, we really don't need a consult. Stunned silence...Things are slowly inproving.

Buckeye....I think your viewpoint is a little obtuse. PCP's are not payed correctly so somehow this must be their fault? Ofcourse some pcp's over consult. So do surgeons and other specialists. It's our culture. But study after study shows that even in primary care's current climate, the more involved a patient's pcp...the better and less costly care rendered. Period. For every egg headed consult a pcp makes...I'll show you a cardiologist who sent a patient to the ER for bronchitis. It's about value int he end. Are PCP's getting paid appropriately for their value to the system. Are specialists value so high that they deserve a 2-3 fold salary?

Jordan-Obtuse? You sound like my wife. Actually, it seems you missed the gist of the post. If a PCP only has ten minutes to spend with each patient, that PCP will farm out all the basic complaints to specialists.

My point was as follows (I'll try not to be obtuse): If we pay fam docs/internists more, they will be able to spend more time with patients and hence, require fewer consults for routine medical problems. They'll get to be doctors once again, instead of rapid assessment triage managers. But it does mean that they'll still have to work hard. No more dumping the bogus chest pain on the cardiologist.

"If a PCP only has ten minutes to spend with each patient, that PCP will farm out all the basic complaints to specialists"

So its sounds like your saying (no value judgement here) that pcp's are forced into seeing patients every ten minutes (to make enough money to survive)and so farm out to specialists because they don't have enough time.

But then you say....What I'm saying is that if primary care docs and internists want to start earning what QB's, I mean specialists, make, then they better be damn good at what they do....This is the world internists have created themselves.

So have internists really created this for themselves...or has the system by paying us so little forced us into this situation to economically survive.

And what does any of this have to do with being good?

News flash....a good internist should be able to workup chest pain, and treat a uti without a consult period. it has nothing to do with time.

Bad internists consult often because they are bad (as well as bad specialists). And good internists consult less because they are good. period. Increasing reimbursement won't change this. Increasing reimbursement won't lead to better care by internists or specialists.

By today's standards PCP's are payed to little when compared to specialists.

Therefore unless something changes there will be very few pcp's in the future. Same probably with general surgeons for that matter!

Jordan-I think we're pretty close on this. My take: if we pay primary more equitably, then the shotgun consultant method of medicine ought to be deemed unacceptable. The concern: that behaviors are so ingrained in the training of medicine residents that many internists will still get GI/surgical/cardiac consults on all ER admits with epigastric pain over the phone no matter how much they are reimbursed....

"News flash....a good internist should be able to workup chest pain, and treat a uti without a consult period. it has nothing to do with time."

Newsflash: It has EVERYTHING to do with time. A good outpatient internist will immediately refer to the ER, chest pain unless it is obviously musculoskelatal in nature. Do you workup questionable chest pain in your clinic?

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